Baltimore Forges Ahead Against Opioids

As Naloxone’s Price Spikes, Baltimore Forges Ahead Against Opioids

By Dr.Fourkan Ali

Volunteers and city health workers have set up a table here at the corner of East Baltimore and North Gay streets – near City Hall in an area filled with peep shows and strip clubs, known to residents as simply "The Block."

Nathan Fields, a community health educator for the city, has been coming to this area regularly for eight years, working with others from the health department to provide needle exchange, HIV testing and reproductive counseling. Today his team is providing passersby with naloxone, a lifesaving drug given to people overdosing on opioids like Oxycontin, Percocet or heroin.

While much publicity has been given to the impact of opioids on rural, middle-aged white Americans, Baltimore's picture looks very different: Blacks comprise more than 60 percent of the population, and as stories of racial tension and police brutality grabbed national headlines last year, the city also lost 393 residents to drug and alcohol overdoses.

But more people are also living thanks to naloxone – at least 400 people last year survived because of it.

Baltimore health commissioner Dr. Leana Wen wants to see the survival rate increase, but she is concerned the drug's recent price hike – from $1 per dose a decade ago to $20 per dose earlier this year and to about $40 per dose now – will get in the way of the city's goals.

"There are very few antidotes that exist in modern medicine; I can count them on two hands," she says. "And if this medication is available then we should make it available to everyone."

Wen wants to get naloxone into the medicine cabinets and first aid kits of the city's 620,000 residents. She declared opioid addiction a public health emergency in Baltimore and has launched one of the most aggressive treatment and prevention programs in the country.

Her efforts are paying off. The Food and Drug Administration will now requirewarning labels on 400 opioids and benzodiazepines, including medications like Valium and Xanax. Wen's signature was the first one listed on a citizen petition calling for the warning.

But the skyrocketing price may halt the progress. The city managed to negotiate a $1 rate for people on Medicaid, but has relied on donations to help with distribution programs. Kaleo, the pharmaceutical company that makes the opioid-antidote EVZIO, donated 8,500 auto-injectors of naloxone to their efforts.

"At the time of a public health crisis, it's unconscionable that our ability to save lives is limited by the price of a medication," Wen says. "That should not happen. … We shouldn't be reliant on charitable donations."

According to Amphastar pharmaceuticals, one of the four companies that makes naloxone, rising costs for materials and labor have driven up the cost of manufacturing the life-saving drug. . The company spent millions of dollars to create a nasal version of its product and to modernize and expand its factory.

A spokesperson for the company points out that, unlike it's competitors, Amphastar has not raised prices since October 2014 and has rebate agreements with nine states. A rebate agreement with Maryland is in the works.

More than 24,000 people use opioids in Baltimore, according to the city's estimates. Theo, 51, who regularly uses the city's needle exchange program and declined to share his last name, believes that naloxone has saved his life three times.

This year alone, he has seen eight people dead from overdoses.

"I stumbled across them in an alleyway or an open building," he says. "Those bodies had been there awhile."

He has been using heroin for 13 years, an addiction that began as he was mourning his father's fatal cancer diagnosis.

"I caught a habit and I ended up liking it so I kept doing it," he says. "I didn't know that heroin had you addicted to the point that you get sick if you don't get it. That's what kept me using."

Baltimore's fight against heroin has been ongoing, but only recently have members of Congress started paying attention. The city's reality is playing out across the country, where deaths from opioids reached28,647 in 2014. Drug overdoses now kill more people than motor vehicle accidents.

Congress this year passed the Comprehensive Addiction and Recovery Act, but critics decried its lack of funding. Making up for this shortfall, this week the White House announced it would provide $53 million in state grants, some of which will go toward purchasing naloxone.

In a meeting with reporters Thursday, Department of Health and Human Services Sec. Sylvia Burwell acknowledged the difficulties in giving people access to the naloxone and keeping it affordable.

"If people aren't getting treated and aren't getting this then we're not making progress," she said. "We need to make progress on both fronts."

In addition to more funding, Wen is calling for more transparency. In testimony before the U.S. Senate in December, she urged Congress to regulate and monitor the price of naloxone.

Despite cost barriers, Baltimore officials have trained 14,000 people and distributed 10,000 doses of naloxone.

On The Block, Fields hands out kits – two doses of naloxone plus a practice injection device that comes with pre-recorded instructions – and teaches people how to use them. One dose can reduce a heroine overdose, but both doses are needed to combat fentanyl, a drug 50 times more potent than heroin, which last year caused a third of Baltimore's drug overdose deaths.

Fields was born in Baltimore, and those walking by on the street know him well, offering him hugs and high fives. He goes into the nightclubs to see what employees need.

"We've built up relationships here," Fields says. "When they ask for resources we have to get it to them."

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One passerby, Sarah Atherton, 46, approaches the table to ask what the volunteers are doing. When offered training on how to use naloxone, she says she isn't likely to know people in a drug overdose situation, and would rather make sure the life-saving drug can reach those who need it most.

"You're not likely to know if you'll know someone who could end up in that situation," Fields counters.

Atherton agrees to the training and receives a certification card. She works for a child advocacy group, and realizes some children have gotten into their parent's methadone, a drug used to counteract the effects of other opioids. Naloxone could save those children.

"I guess you're right," Atherton says to Fields. "People will surprise you."

Another passerby, Scott Brunner, 28, accepts the training and free naloxone.

He says he has seen people high on opioids at bus stops. He once went to turn a woman onto her side to help her breathe when she collapsed and began shaking and foaming at the mouth, presumably from a overdose.

"I already know CPR," he says. "This is going to make me feel like a hero."